Surgery to re­move wis­dom teeth puts some young pa­tients on path to opi­oid use

The Jerusalem Post - - HEALTH & SCIENCE - • By MELISSA HEALY

For older teens and young adults, the ex­trac­tion of so-called wis­dom teeth is a painful rite of pas­sage. A new study sug­gests it is likely made more per­ilous by the pack­age of nar­cotic pain pills that pa­tients fre­quently carry home af­ter un­der­go­ing the com­mon sur­gi­cal pro­ce­dure.

The study of­fers fresh ev­i­dence of how read­ily – and in­no­cently – a po­ten­tially fa­tal ad­dic­tion to opi­oids can take hold. It also un­der­scores how im­por­tant it is that den­tists re­think their ap­proach to treat­ing their pa­tients’ post­op­er­a­tive dis­com­fort.

In a group of close to 15,000 peo­ple whose first-ever pre­scrip­tion for opi­oid painkillers came from a den­tist or den­tal sur­geon, re­searchers found that about 7% filled an­other opi­oid pre­scrip­tion 90 to 365 days later. In the year fol­low­ing their den­tal pro­ce­dure, close to 6% of pa­tients who left their den­tist’s of­fice with a pre­scrip­tion for opi­oids had a “health care en­counter” – a hos­pi­tal­iza­tion or trip to the emer­gency room, a physi­cian con­sul­ta­tion, or a ses­sion with an ad­dic­tion spe­cial­ist – in which a di­ag­no­sis of opi­oid abuse was doc­u­mented.

That’s well over 10 times the rate at which a com­par­i­son group of pa­tients who did not re­ceive a pre­scrip­tion for opi­oid painkillers got that di­ag­no­sis. Pa­tients in both groups were 16 to 25 years old, and all were treated by den­tists dur­ing 2015. Re­searchers then were able to track the pa­tients for at least a year.

Com­pared with the study’s boys and young men, girls and young women were more likely to con­tinue us­ing nar­cotic pain relievers af­ter get­ting their wis­dom teeth out, and they were much more likely to abuse the drugs.

The typ­i­cal pre­scrip­tion ca­pa­ble of set­ting such havoc into mo­tion was a pack of about 20 pills of an opi­oid nar­cotic such as OxyCon­tin, Vi­codin or Per­co­cet.

Pub­lished this week in the jour­nal JAMA In­ter­nal Medicine, the new research comes at a time when opi­oid drugs are claim­ing the lives of 115 Amer­i­cans a day. Al­though those fa­tal­i­ties are also caused by street drugs such as heroin and, in­creas­ingly, syn­thetic opi­oids such as fen­tanyl, as many as 80% of those ad­dicted to heroin say they started by abus­ing med­i­ca­tions that were pre­scribed for le­git­i­mate pur­poses.

That in turn has shined a light on the med­i­cal pro­fes­sion’s pre­scrib­ing prac­tices and its role in the pub­lic health cri­sis. In 2016, as the epi­demic of over­dose deaths con­tin­ued its steep rise, those in the med­i­cal and den­tal pro­fes­sions pre­scribed enough painkillers to med­i­cate ev­ery Amer­i­can daily for close to a month.

Al­though many of those pills are pre­scribed to man­age the agony of pa­tients with ex­cru­ci­at­ing pain con­di­tions, physi­cians and den­tists still pre­scribe opi­oids to pa­tients whose pain could be treated more safely, and just as ef­fec­tively, with non­nar­cotic drugs.

The new study also calls into ques­tion the wis­dom of rou­tinely ex­tract­ing those pesky mo­lars that tend to push through our rear-most gums in late ado­les­cence or early adult­hood, of­ten crowd­ing other teeth or be­com­ing im­pacted.

Study au­thor Dr. Alan R. Schroeder, a Stan­ford Univer­sity pe­di­a­tri­cian with an in­ter­est in “safely do­ing less,” said the ben­e­fits of wis­dom tooth ex­trac­tion have not been rig­or­ously stud­ied or demon­strated. Nor, he added, have its risks.

Study­ing the risk of opi­oid ad­dic­tion or abuse, at least, seemed a good place to start, he said.

The sur­gi­cal re­moval of wis­dom teeth comes with such po­ten­tial down­sides as dry sock­ets, gum pain and nerve dam­age, as well as risks as­so­ci­ated with the anes­the­sia used dur­ing those pro­ce­dures.

And then there are the drugs. Den­tal sur­geons have been among the most lib­eral pre­scribers of opi­oid painkillers, and they’re also heavy pre­scribers of an­tibi­otics. Those med­i­ca­tions can come with side ef­fects of their own, and over-pre­scrip­tion is be­lieved to fos­ter the rise of an­tibi­otic-re­sis­tant in­fec­tions in pop­u­la­tions.

In­deed, Schroeder said, the dearth of research about wis­dom tooth ex­trac­tion makes its fre­quency hard to judge. And that, in turn, forced Schroeder and his coau­thors to make a key as­sump­tion in their study.

Den­tal in­surance data­bases are scarce and many wis­dom tooth ex­trac­tions are paid for out of pocket. But given the age of most of the pa­tients leav­ing a den­tist’s of­fice with an opi­oid pre­scrip­tion, Schroeder and his coau­thors fig­ured the most likely cause was wis­dom tooth surgery (a third-mo­lar ex­trac­tion in den­tal par­lance). The au­thors’ con­clu­sion that opi­ate abuse is a pos­si­ble risk of wis­dom tooth re­moval rests on this as­sump­tion.

But when you con­sider how many young peo­ple have their wis­dom teeth re­moved, and how rou­tinely den­tists send their pa­tients home with a pre­scrip­tion for nar­cotic pain re­lief, the im­pli­ca­tions are pretty alarm­ing. An un­pub­lished 1999 study by the Amer­i­can Den­tal As­so­ci­a­tion and cited by the au­thors es­ti­mated that about five mil­lion such ex­trac­tions are per­formed per year. By 2009, an­other study had con­cluded that den­tists were the lead­ing source of opi­oid pre­scrip­tions for chil­dren and ado­les­cents ages 10 to 19, ac­count­ing for close to onethird of opi­oid pre­scrip­tions in this age group.

The ADA, mean­while, has vowed that its mem­bers will re­duce their opi­oid pre­scrib­ing. In a state­ment re­leased in March, then-pres­i­dent Dr. Joseph P. Crow­ley called on den­tists to “dou­ble down on their ef­forts” to write fewer pre­scrip­tions of opi­oids for den­tal pain, to lower the doses that are pre­scribed, and to shorten the duration of pre­scrip­tions – all mea­sures known to re­duce ad­dic­tion risk. The as­so­ci­a­tion has also backed state leg­is­la­tion to limit opi­oid pre­scrip­tions’ dosage and duration, and to track med­i­cal pro­fes­sion­als’ pre­scrib­ing prac­tices.

“The den­tal pro­fes­sion de­serves credit for try­ing to tackle this,” Schroeder said. “It’s easy to point the fin­ger at den­tists – over time, they have con­trib­uted a fair amount of the opi­oid ex­po­sure. But they re­ally have made ef­forts to limit that in re­cent years.”

(LA Times/TNS)


PEO­PLE WHOSE first-ever pre­scrip­tion for opi­oid painkillers came from a den­tist or den­tal sur­geon are more likely to fall vic­tim to opi­oid abuse.

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